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Idea Transcript


Case Study

Organized Health Care Delivery System • June 2009

HealthPartners: Consumer-Focused Mission and Collaborative Approach Support Ambitious Performance Improvement Agenda D ouglas M c C arthy, K imberly M ueller, I ssues R esearch , I nc . The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.

To download this publication and learn about others as they become available, visit us online at www.commonwealthfund.org and register to receive Fund e-Alerts. Commonwealth Fund pub. 1250 Vol. 12

I ngrid Tillmann

ABSTRACT: HealthPartners is the nation’s largest nonprofit, consumer-governed health care organization, providing health and dental care and coverage to more than 1 million individuals in Minnesota and surrounding states. Key factors driving HealthPartners’ performance are a consumer-focused mission; a regional focus, scale, and scope integrating a broad range of services; strategic use of electronic health records to support care redesign; and a culture of continuous improvement. A comprehensive model for improvement includes setting ambitious targets for health system transformation; measuring what is important in order to optimize care; agreeing on best care practices and supporting improvement at the clinic level; aligning incentives with goals; and making results transparent internally and externally. HealthPartners’ experience suggests that a nonprofit health plan market oriented to physician group practice—supported by collaborative measurement, improvement, and reporting structures—creates a community environment that helps each participant achieve objectives more effectively.

For more information about this study, please contact: Douglas McCarthy, M.B.A. Issues Research, Inc. [email protected]

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OVERVIEW In August 2008, the Commonwealth Fund Commission on a High Performance Health System released a report, Organizing the U.S. Health Care Delivery System for High Performance, that examined problems engendered by fragmentation in the health care system and offered policy recommendations to stimulate greater organization for high performance.1 In formulating its recommendations, the commission identified six attributes of an ideal health care delivery system (Exhibit 1). HealthPartners is one of 15 case-study sites that the commission examined to illustrate these six attributes in diverse organizational settings. Exhibit 2 summarizes findings for HealthPartners, focusing primarily on the ambulatory care

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Exhibit 1. Six Attributes of an Ideal Health Care Delivery System •

Information Continuity Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.



Care Coordination and Transitions Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.



System Accountability There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination since one supports the other.)



Peer Review and Teamwork for High-Value Care Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care.



Continuous Innovation The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.



Easy Access to Appropriate Care Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs.

setting. Information was gathered from HealthPartners’ system leaders and from a review of supporting documents.2 The case-study sites exhibited the six attributes in different ways and to varying degrees. All offered ideas and lessons that may be helpful to other organizations seeking to improve their capabilities for achieving higher levels of performance.3

ORGANIZATIONAL BACKGROUND HealthPartners, headquartered in Minnesota’s Twin Cities, is the nation’s largest nonprofit, consumergoverned healthcare organization. Its mission is to “improve the health of our members, our patients, and the community.” The organization was formed through a 1992–1993 merger between Group Health, one of the nation’s oldest staff-model health maintenance organizations (HMOs) founded in 1957; MedCenters Health Plan, a network-model HMO; and Regions Hospital (formerly St. Paul-Ramsey Medical Center), a 427-bed teaching hospital and level I trauma center. Two 25-bed critical-access hospitals have since joined the system: Westfields Hospital in New Richmond, Wisconsin, and Hudson Hospital and Clinics in Hudson, Wisconsin.

Today, HealthPartners provides individual, group, and public insurance coverage to more than 1 million members of health and dental plans in Minnesota, western Wisconsin, North and South Dakota, and Iowa (Exhibit 3). Members receive care from a network of some 30,000 providers including both owned and contracted medical groups, specialty clinics, hospitals, and dental practices. Other lines of business include behavioral health, eye care, disease management, integrated home care and hospice, pharmacy, wellness, and personalized health promotion for individuals and groups. The organization employs almost 10,000 and has annual revenue of $3.1 billion. About one-third of HealthPartners’ 640,000 health plan members receive care from the HealthPartners Medical Group (HPMG), a multispecialty group practice that employs more than 600 physicians who practice at 50 HealthPartners clinic locations throughout the Twin Cities and in St. Cloud and Duluth, Minn. (Exhibit 4). HPMG also provides care for patients who have other insurance (including Medicare or Medicaid), who represent about 40 percent of the medical group’s 400,000 patients. Each

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Exhibit 2. Case Study Highlights Overview: HealthPartners is a family of nonprofit, consumer-governed, integrated health care organizations including a teaching hospital and two critical-access hospitals; the multispecialty HealthPartners Medical Group (HPMG), with more than 600 physicians practicing in 50 clinics; health and dental plans offering group, individual, and public insurance cover­age to more than 1 million individuals through a network of 30,000 providers in Minnesota, western Wisconsin, North and South Dakota, and Iowa; a research foundation; and a medical-education institute. Attribute

Examples from HealthPartners

Information Continuity

Enhanced electronic health record (EHR) system. Patient information is integrated across HPMG clinics with disease registries, clinical reminders, safety alerts, and evidence-based decision support to guide care processes before, during, and after the patient visit. Online personal health record and health assessment. HPMG patients also can schedule ap­pointments, refill prescriptions, share secure e-mail with clinicians, receive preventive care reminders, and view lab results, medications, and immunizations online. Participation in Minnesota Health Information Exchange. Secure interchange of clinical information will facilitate patients’ movement among medical groups and health systems.

Care Coordination and Transitions; System Accountability*

EHR supports care transitions for HPMG heart-failure patients after hospital discharge. Chronic disease management programs iden­tify eligible health plan members, engage them in self-care, and promote medica­tion compliance, appropriate treatment, home monitoring, communication, and follow-up in coordination with primary care physician. For example: Behavioral health management includes early intervention program to identify and refer members at risk of depression or problem drinking, medication management programs to promote treatment adherence, and case management to coordinate services for members at risk of behavioral health crises. Workplace wellness programs foster population health improvement by assessing employees for health risks, offering telephonic coaching and education to support lifestyle changes, and promoting engagement through incentives.

Peer Review and Teamwork for High-Value Care Continuous Innovation

Prepared Practice Teams in HPMG primary care clinics use a “Care Model Process” and EHR to standardize care processes, anticipate patient needs, give evidence-based care, and ensure follow-up after visits. Comprehensive improvement model disseminated through leadership teams, workforce development, and participation in collaborations such as the Institute for Clini­cal Systems Improvement help develop common clinical guidelines and improvement strategies. Elements in­clude: (1) set ambitious targets for health system transformation, (2) measure what is important in order to optimize care, (3) agree on best care practices and support improvement at the clinic level, (4) align incentives with goals, and (5) make results transparent. Performance feedback and incen­tives and tiered networks en­courage contracted providers to improve value.

Easy Access to Appropriate Care

Health plan offers “nurse navigators,” after-hours nurse-advice call line, and open-access options with no referral required to see a specialist. Advanced-access scheduling is associated with reduced appointment waiting time and increased continuity of care with the same provider in HPMG primary care clinics. Walk-in urgent care and retail convenience clinics seek to integrate with traditional clinics. Well@Work work-site clinics offer acute care and health promotion. Cultural competency initiatives include professional transla­tors, translated materials, educa­tional resources, and the collection of demographics at point of care.

*System accountability is grouped with care coordination and transitions, since these attributes are closely related.

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Exhibit 3. HealthPartners Network Area

Source: HealthPartners.

clinic, and the medical group as a whole, is led by a physician-administrator pair. The HealthPartners Research Foundation conducts clinical, health-services, and basic science research in the public domain, with a focus on improving health care and health through partnerships with care delivery organizations. The HealthPartners Institute for Medical Education sponsors 16 medical residency programs and 240 continuing medical education programs. The institute jointly sponsors the

HealthPartners Simulation Center for Patient Safety at Metropolitan State University, which provides “realistic hands-on experiential learning opportunities” for health care professionals and medical and nursing students from Minnesota and neighboring states. Minnesota, and the Twin Cities in particular, has been a leader in developing innovative approaches to health care financing and delivery, with a continuing orientation toward physician group practice. Public and private employers are collectively active in value-based

Exhibit 4. HealthPartners Medical Group Clinic Locations

Source: HealthPartners.

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purchasing initiatives that develop shared strategies to promote quality and cost-containment goals.4 Several collaborative organizations bring stakeholders together to develop common clinical guidelines, improvement strategies, measurement metrics, and performance reporting and incentive programs (see Appendix A). By law, HMOs are nonprofit organizations in Minnesota. Three large health plans—HealthPartners, Medica, and Blue Cross Blue Shield—dominate the market.5

INFORMATION CONTINUITY All HealthPartners Medical Group clinicians have access to electronic health records (EHRs) for their patients. The EHR was implemented in stages beginning with pilot sites in the 1990s. In 2001, the medical group implemented online medication ordering and simple documentation using a basic Web-based EHR. By 2003, the group determined that it needed a more robust EHR providing four key capabilities: chart review, physician-order entry (including medications, laboratory tests, and images), documentation, and bestpractice alerts and reminders. HealthPartners selected and enhanced a third-party software system (EpicCare from Epic Systems Corp.) to meet these requirements. Installation was completed in primary care clinics by 2005, Regions Hospital by 2006, and specialty and behavioral health clinics by 2008. HealthPartners has customized the EHR to include advanced capabilities such as disease registries, clinical reminders, safety alerts, and decision support for evidence-based guidelines. Panels of medical experts developed clinical content in core topic areas that was embedded in the EHR to support the delivery of preventive and chronic care services before, during, and after the patient visit. In contrast to stand-alone disease registries, the EHR integrates patient information across health conditions so that clinicians can have a unified view of a patient’s history.6 The health plan supplies chronic disease registry data to its contracted medical groups so that physicians can track and identify their patients who are in need of evidence-based chronic care services. Medical groups that have an EHR can import the data into their

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own system to add information that is not available in ambulatory care records, such as hospital admissions and ER visits. All health plan members can create an online personal health record (PHR) to keep a medical history, track health goals, take an online health assessment, and view their medical claims. Patients of the HealthPartners Medical Group can access additional online capabilities to schedule doctor appointments, request prescription refills, send secure e-mail communications to their care team (“e-visits”), receive e-mail reminders for preventive or chronic care, and view their laboratory test results, medication lists, and immunization records. In adopting this technology, HealthPartners aimed to promote a more collaborative relationship between patients and caregivers while also giving patients greater control of information to better manage their own health.7 HealthPartners is participating in a public– private partnership called the Minnesota Health Information Exchange to enable the secure exchange of clinical information such as medical histories, laboratory orders, and test results between providers and payers as patients move among medical groups and health systems.

CARE COORDINATION AND TRANSITIONS: TOWARD GREATER ACCOUNTABILITY FOR TOTAL CARE OF THE PATIENT Improving care transitions. The HealthPartners Medical Group and Regions Hospital are working together to improve care transitions for patients with heart failure, according to Beth Averbeck, M.D., associate medical director for primary care. For example, primary care physicians receive an electronic alert when one of their heart failure patients is admitted to Regions hospital. When the patient is discharged, the hospital’s care managers notify the medical group’s heart failure clinic and telephone the patient at home to ensure that he or she has a follow-up appointment and is taking the proper medications. The patient’s primary care physician and a cardiac specialist in the heart failure clinic then comanage the patient with a jointly

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agreed-upon follow-up schedule, using the EHR to facilitate communication and patient reminders. To promote improved care transitions across its network, the health plan recently began reporting on hospital readmissions for heart failure patients in each of its cardiology care groups. As part of its performance incentive program for contracted providers (described below), the plan has set a goal of reducing readmissions within 30 and 90 days of an initial hospitalization to 5 percent and 15 percent of these patients, respectively, from current planwide rates of 7.9 percent and 17.3 percent during 2005–2007.8 Managing chronic disease. HealthPartners has engaged in a series of innovative and collaborative disease management activities since the early 1990s, focused initially on diabetes. The authors of a previous Commonwealth Fund report noted that the integrated nature of HealthPartners Medical Group (formerly the staff-model HMO) likely reduced the costs and increased the success of developing disease management programs in comparison to efforts by looser networks of independent physicians. They estimated that the economic value of improved quality of life (from reduced disease complications) would be $31,000 for a diabetic patient who participated in the program for 10 years.9 The health plan now offers a suite of disease management programs under the name CareSpan that can be purchased by employer groups for their health plan members with conditions such as asthma, diabetes, heart disease, heart failure, and chronic obstructive pulmonary disease. CareSpan uses disease registries, health assessments (described below), and referrals from physicians to identify patients who would benefit from early intervention, disease management, and case management programs. Participants receive personalized education and support from nurses or other professionals such as dieticians for self-care, medication compliance, home monitoring, and follow-up as needed in coordination with their physician and clinic. The plan reported the following audited results for participants in these programs from 2003–2004 to 2005–2006:

• 6 percent reduction in all-cause admissions for members with asthma • 5 percent reduction in all-cause admissions for members with diabetes • 13 percent reduction in admissions for heart attack, heart bypass surgery (CABG), and chest pain (angina) for members with coronary artery disease • 6 percent reduction in all-cause admissions for members with chronic heart failure. Improving behavioral health. Behavioral health management programs illustrate how HealthPartners is seeking to develop a proactive approach to care management that supports the relationship between patients and their physicians (or other providers) but does not rely exclusively on a patient visit to identify and address health problems. These programs are part of the organization’s broader strategy to promote health by removing barriers so that health plan members can more easily access mental health or chemical health evaluation and treatment services when needed, according to Karen Lloyd, senior director of behavioral health strategy and operations. For example, a behavioral health direct-access network allows members to see any outpatient behavioral health professional without prior approval or authorization. In an early intervention program, licensed behavioral health professionals (social workers or psychologists) contact health plan members whose health assessment indicates a risk for depression or problem drinking—two modifiable risk factors that can affect a person’s productivity and ability to manage a chronic disease. During the outreach call, the behavior health professional conducts additional screening to ascertain the nature of the individual’s concerns or symptoms. If the individual appears to have an undiagnosed, clinically treatable condition, the professional provides education and guidance to motivate him or her to see a behavioral health professional for a full evaluation. Those with subclinical conditions are offered guidance and provided educational resources on how to reduce their risk for developing depression or alcohol dependency.

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A behavioral health disease management program focuses on health plan members with depression who are beginning antidepressant medication. The program sends these members monthly educational material and reminders to refill their prescriptions for six months. The member’s physician receives a letter if the patient fails to refill his or her medication in a timely manner. Anecdotal feedback suggests that physicians find this service useful for prompting follow-up with patients. The health plan credits this program with a 17 percent improvement in rates of six-month medication adherence.10 The plan has expanded the program to promote medication adherence and improved self-care among members with bipolar disorder or schizophrenia, two conditions that put an individual at high risk for poor health outcomes. In addition to sending refill reminders, the program offers brief telephone counseling and referral for those who are not adhering to treatment. This program puts a special emphasis on maintaining physical health, as research indicates that patients with severe mental illness and taking atypical antipsychotic medications lose an average of 25 years of lifespan. Several years ago the health plan implemented a telephonic case management program after discovering that 5 percent of its members with behavioral health– related diagnoses accounted for 50 percent of expenditures. The program uses a predictive algorithm to identify members who are at risk of behavioral health crises and hospitalizations. A behavioral health case manager invites these members to participate (by letter and then by phone) and provides participants with self-care education, health coaching, decision support, and care coordination services. Case managers can access the EHRs of patients seeing physicians in the HealthPartners Medical Group to facilitate care planning and communication with the care team. In 2007, the engagement rate was about 38 percent and participant satisfaction was 94 percent. Similar case management services are offered to all health plan members with illnesses that put them at risk for poor outcomes and high costs.

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The plan’s analysis of program effectiveness comparing the study group (whether engaged in the program or not) to a historical comparison group (with costs trended forward) found that ambulatory behavioral health visits were 35 percent higher among the study group, medication costs per member per month were 11 percent lower, inpatient behavioral health days per 1,000 members were 4 percent lower, and costs per member per month were 18 percent lower in the latest annual measurement period.11 The overall return on investment was estimated at $4 saved in medical costs for every $1 spent on program administration. Recently, the plan has found that residential chemical health days have increased as inpatient mental health days have decreased. Anecdotal information suggests that many members at highest risk for hospitalization have an undiagnosed or untreated chemical health condition coexisting with a mental health condition. Promoting healthy lifestyles. The health plan encourages each adult member to complete an online health assessment (integrated with his or her personal health record) designed to identify those at risk of developing chronic illnesses, such as diabetes or heart disease, who would benefit from prevention.12 Participants receive immediate online feedback via a personal report featuring a modifiable risk score (including the change in score since a previous assessment) and an action plan for making lifestyle changes. Results are used to invite the member to participate in disease management programs for which they may be eligible. While health plan–initiated communications strategies help to raise members’ awareness of this service, they have not resulted in high participation rates, nor are physicians always prepared to use such information in clinical practice. HealthPartners has found that the most effective strategy for engaging individuals in healthy lifestyles is to implement the online health assessment together with employer-sponsored programs for improving population health. The health assessment “is a powerful tool to create ‘teachable moments’ for people that can help mobilize them [into] taking active steps to

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health improvement,” said Nico Pronk, Ph.D., vice president and health science officer at HeathPartners’ JourneyWell program for employers. Realizing this potential requires an integrated approach to connecting employees with programs, he said. To meet this need, HealthPartners works with employers locally and nationally to develop workplace health programs that offer incentives (such as reduced copayments and deductibles) for employees to engage in annual health assessments and follow-up programs. These programs include curriculum-based telephonic counseling and educational courses to support individuals in making lifestyle changes such as smoking cessation or weight loss, online programs to promote increased physical activity levels, and referral to disease management programs and to workplace-specific resources such as employee assistance programs. One large Twin Cities employer, BAE Systems, experienced the following results after participating in such a program for three years: • high levels of reported employee satisfaction with the program • sustained participation rates of 89 percent or higher annually among the company’s 1,300 employees and their spouses • 6 percent improvement in employees’ modifiable risk scores and health behaviors • 3.3 percent annual reduction in medical claims costs (about half of which was attributed to lower-than-expected hospital admissions), equal to about $59 per employee per year and yielding a 2:1-to-3:1 return on investment • improved workforce productivity valued at more than $1 million.13

PEER REVIEW AND TEAMWORK FOR HIGH-VALUE CARE Physicians in the HealthPartners Medical Group engage in a formal peer review process at the departmental level. Cases are referred for review based on patient or staff concerns, with a focus on identifying learning

opportunities and systems issues to be addressed for improvement. Physicians are invited to join quality improvement teams and to receive training in improvement methods based on their clinical interests. The goal is to develop informal leaders who will spread knowledge and mentor their peers, said Averbeck. Primary care clinics within the HealthPartners Medical Group have adopted a “Care Model Process” (adapted from Wagner’s Chronic Care Model14) that defines “a standard set of workflows for delivering evidence-based care that provides a consistent clinical experience for patients and a consistent process for care teams.”15 Each clinic’s staff is organized into “prepared practice teams” composed of a physician, a rooming nurse, a receptionist, and others such as a pharmacist or dietician when needed for particular patients. The goal is to create a “continuous healing relationship” between caregivers and patients by making the best use of collective team skills, enhancing communication, and ensuring that care is well-coordinated and responsive to patient needs. These teams typically huddle each morning to review their schedule and objectives for the day. Through standardization of processes and clearer specification of roles, the care team focuses on reliably performing core patient interactions within a defined patient visit cycle—scheduling, pre-visit, check-in, visit, and post-visit—to anticipate patient needs, remind patients of health issues, and provide follow-up after the visit. For example, pre-visit planning may include identifying preventive care services that will need to be provided at the visit and contacting the patient to schedule laboratory tests so that results are available for review during the visit. At the patient visit, the team uses the EHR to address the patient’s health maintenance and/or chronic care needs, refill prescriptions if needed, and schedule future appointments. Patients receive an “after-visit summary” of their care plan to promote treatment adherence and receive outstanding lab results by their preferred method of notification (letter, phone, or e-mail). Implementation of the Care Model Process, along with other interventions, was associated with improvements in the quality of care received by

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primary care patients, while also laying a foundation for making future improvements in care.16

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and invited to schedule a visit or other needed services.

• Pre-visit planning activities increased from 8 percent of patients in 2005 to 70 percent in 2006 (with improvement continuing to more than 90 percent of patients today), and accuracy of health maintenance records rose from 56 percent to 95 percent and has remained near that level since that time (Exhibit 5). • Patients receiving optimal diabetes care— measured as a composite, or “bundle,” of five treatment goals including control of blood glucose, blood pressure, and cholesterol levels; aspirin use; and non-use of tobacco—increased from 4 percent of diabetic patients in 2004 to 15 percent in 2006 and 25 percent in the fourth quarter of 2008 (Exhibit 6). This increase builds on more than a decade of work to improve the quality of diabetes care.17 Recent improvements were facilitated by the use of a monthly “exceptions report” that identifies diabetic patients who are not up-to-date on plannedcare visits, have missed follow-up care, or are not achieving treatment goals. These patients are contacted by telephone or electronic reminder

• Incorporating the PHQ-9 patient health questionnaire, an assessment tool for depression, into the primary care visit cycle (completed by the patient and documented in the EHR by the rooming nurse) resulted in a doubling of patients who use it, from 32 percent of primary care clinic patients with newly diagnosed depression in 2004 to 65 percent in 2007. The tool provides a structured way for physicians to communicate with patients about their symptoms and to make treatment adjustments as needed.18 • Patient satisfaction (percentage reporting a problem) has improved 24 percent since 2006 as the intervention has shifted focus to improving the patient experience. Areas of attention included improving communication with patients about expected waiting time, training staff to consistently demonstrate respect, and making sure that the patient’s main reason for the visit has been addressed. The medical group developed the Care Model Process starting in 2002 through its participation in the Pursuing Perfection initiative, funded by the Robert Wood Johnson Foundation and led by the Institute for

Exhibit 5. HealthPartners Medical Group Care Model Process: Summary of Implementation Results Baseline (Apr.–Jul. 2005)* 100 80

After implementation (Feb. 2006) 95

86 75

70 56

60

35

40 20 0

50

8 Visit scheduling

Pre-visit planning

Health maintenance

Opportunity management

Note: Visit scheduling = percent of primary care visits scheduled where patient was offered needed health maintenance screening; Pre-visit planning = percent of primary care visits that pre-visit planned; Health maintenance = percent of primary care patients where the electronic medical record accurately reflects the patient’s needs; Opportunity management = percent of patients will all health maintenance services discussed, offered, ordered, scheduled, and/or provided at the primary care visit. Source: M. McGrail and B. Waterman, “HealthPartners Medical Group: Care Model Process,” Group Practice Journal, Nov.–Dec. 2006 55(10):9–20.

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Exhibit 6. HealthPartners Medical Group: Achieving Optimal Diabetes Care Percent of diabetic patients achieving all five treatment goals* 30 25

25 20 14

15

15

14

10 5 0

4 2004

2005

2006

2007

2008*

*Optimal diabetes care means the percentage of patients aged 18 to 75 with diabetes (Type 1 or 2) who had hemoglobin A1c

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